• Journal of Korean Neurosurgical Society
• /
• v.61 no.2
• /
• pp.201-211
• /
• 2018

Objective : The purpose of this study was to analyze the variability of clopidogrel responses according to duration of a clopidogrel drug regimen after stent-assisted coil embolization (SAC), and to determine the correlation between the variability of clopidogrel responses and thromboembolic or hemorrhagic complications. Methods : A total of 47 patients who underwent SAC procedures to treat unruptured intracranial aneurysms were enrolled in the study. Preoperatively, patients received more than seven days of aspirin (100 mg) and clopidogrel (75 mg), daily. P2Y12 reaction unit (PRU) was checked with the VerifyNow test one day before the procedure (pre-PRU) and one month after the procedure (post-PRU). PRU variability was calculated as the difference between the initial response and the follow-up response. Patients were sorted into two groups based on their response to treatment : responsive and hypo-responsive. Results : PRU variability was significantly greater in the hypo-responsive group when compared to the responsive group (p=0.019). Pre-PRU and serum platelets counts were significantly correlated with PRU variation (p=0.005 and p=0.004, respectively). Although thromboembolic complication had no significant correlated factors, hemorrhagic complication was correlated with pre-PRU (p=0.033). Conclusion : In conclusion, variability of clopidogrel responses during clopidogrel medication was correlated to serum platelet counts and the initial clopidogrel response. Thromboembolic and hemorrhagic complications did not show correlation with the variability of clopidogrel response, or the clopidogrel response after one month of medication; however, hemorrhagic complication was associated with initial clopidogrel response. Therefore, it is recommended to test patients for an initial clopidogrel response only, as further tests would be insignificant.

• Archives of Plastic Surgery
• /
• v.50 no.3
• /
• pp.248-253
• /
• 2023

Metal fixation systems for cranial bone flaps cut by a drill are convenient devices for cranioplasty, but cause several complications. We use modified craniotomy using a fine diamond-coated threadwire saw (diamond T-saw) to reduce the bone defect, and osteoplasty calcium phosphate cement without metal fixation. We report our outcomes and tips of this method. A total of 78 consecutive patients underwent elective frontotemporal craniotomy for clipping of unruptured intracranial aneurysms between 2015 and 2019. The follow-up periods ranged from 13 to 66 months. The bone fixation state was evaluated by bone computed tomography (CT) and three-dimensional CT (3D-CT). The diamond T-saw could minimize the bone defect. Only one wound infection occurred within 1 week postoperatively, and no late infection. No pain, palpable/cosmetically noticeable displacement of the bone flap, fluid accumulations, or other complications were observed. The condition of bone fixation and the cosmetic efficacy were thoroughly satisfactory for all patients, and bone CT and 3D-CT demonstrated that good bone fusion. No complication typical of metal fixation occurred. Our method is technically easy and safety, and achieved good mid-term bone flap fixation in the mid-term course, so has potential for bone fixation without the use of metal plates.

• Journal of Korean Neurosurgical Society
• /
• v.39 no.3
• /
• pp.192-197
• /
• 2006

Objective : Eleven patients treated with posterior cerebral artery[PCA] aneurysm during 6.3-years period are retrospectively reviewed to determine treatment outcome. Methods : Eleven patients with PCA aneurysm were treated from January 1998 to May 2004. Their medical records and radiologic studies were reviewed retrospectively. The records of these patients were analysed with particular reference to their demographic details, mode of presentation, and treatment outcome. Results : Of the 11 patients, 8 patients presented with symptoms related aneurysmal bleeding. Three patients had unruptured PCA aneurysms. Open or endovascular surgery was performed in 9 patients; None of these patients exhibited a third nerve palsy, visual field deficit, or hemiparesis at the time of presentation. Postoperatively, 2 made a good recovery, 2 had a moderate disability because of cerebral infarction after surgery, and 5 had a severe disability because of cerebral infarction after surgery. Of 2 conservatively treated patients, 1 was doing well but the other died as a result of brain swelling. Conclusion : The treatment of the PCA aneurysms is difficult regardless of the aneurysmal size, site, and treatment modality. All reasonable treatment to reduce the risk of associated morbidity should be considered.

• Journal of Cerebrovascular and Endovascular Neurosurgery
• /
• v.25 no.2
• /
• pp.182-188
• /
• 2023

Objective: To report our experience with intraprocedural rupture (IPR) of intracranial aneurysms during endovascular treatment and evaluate alterations in vital signs as independent prognostic factors to predict the outcomes of IPR. Methods: Between January 2008 and August 2021, 34 patients (8 ruptured and 26 unruptured) were confirmed to have IPR based on our dataset with 3178 endovascular coiling procedures. The patients who underwent additional surgeries related to IPR were classified as the OP group (n=9), while those who did not receive additional surgeries were classified as the non-OP group (n=25). Vital signs were recorded during the procedure by anesthesiologists and analyzed. Results: Of the 34 patients included in this study, eight initially presented with subarachnoid hemorrhage due to a ruptured aneurysm. The clinical outcomes at discharge were significantly different between the two groups (p=0.046). In the OP group, five patients showed favorable outcomes at discharge, while four showed unfavorable outcomes. In the non-OP group, 23 patients showed favorable outcomes at discharge while two patients showed unfavorable outcomes. Maximal (MAX) systolic blood pressure (SBP) (odds ratio [OR] 1.520, 95% confidence interval [CI] 1.084-2.110; p=0.037) and higher differential value MAX-median blood pressure (MBP) (OR 1.322, 95% CI 1.029-1.607; p=0.044) remained independent risk factors for poor prognosis after IPR on multivariate logistic regression analysis. Conclusions: The MAX SBP and the difference between the maximal and baseline values of MBP are key factors in predicting the prognosis of patients after IPR, as well as providing useful information for predicting the outcome. Further research is required to confirm the relationship between naive pressure and prognosis.

• Journal of Korean Neurosurgical Society
• /
• v.67 no.5
• /
• pp.531-540
• /
• 2024

Objective : The use of reconstructive treatment with a double-overlapping stents has proven to be effective and safe in the current treatment of intracranial vertebral artery dissecting aneurysms (VADAs). We employed a combination of overlapping stents, using low-profile visualized intraluminal support (LVIS) within the Enterprise stent. This combination was chosen to minimize the outward bulging of the inner LVIS by overlapping it with the Enterprise stent while maintaining flow diversion and stability. This study aimed to evaluate the clinical and angiographic outcomes following the use of double-overlapping stents with LVIS within the Enterprise stent for the treatment of VADAs. Methods : From March 2016 to January 2022, total 28 patients with unruptured VADAs were treated with the double-overlapping stent technique using LVIS within an Enterprise stent in our institute. The Enterprise stent was deployed first, followed by the LVIS stent. Patient clinical and angiographic characteristics, procedural complications, and follow-up outcomes were retrospectively reviewed. Results : All 28 patients (18 males and 10 females) were successfully treated with double-overlapping stent deployment. There were no procedural complications or new neurological deficits in any patient. Of the 28 patients, four VADAs had posterior inferior cerebellar artery involvement. Procedure-related parent artery occlusion did not occur during the angiographic follow-up conducted 6 to 12 months after the procedure. Out of 28 patients, 24 showed complete healing, three had focal residual stenosis or dilatation with residual sac and only one had a residual dissecting flap with aneurysm. All patients, including the four patients, did not require any additional procedures. The postoperative modified Rankin scale scores were 0-1 for all patients. Conclusion : A double-overlapping stent, with a flow-diversion effect, is a safe and effective treatment for patients with VADAs. In particular, when using the LVIS stent within an Enterprise stent, it minimizes the bulging of the inner LVIS stent while maintaining flow diversion and stability. Therefore, both can be effectively utilized as overlapping stents.

• Journal of Korean Neurosurgical Society
• /
• v.51 no.4
• /
• pp.222-226
• /
• 2012

The waffle-cone technique is a modified stent application technique, which involves protrusion of the distal portion of a stent into an aneurysm fundus to provide neck support for subsequent coiling. The authors report two cases of wide necked basilar bifurcation aneurysms, which were not amenable to stent assisted coiling, that were treated using the waffle-cone technique with a Solitaire AB stent. A 58-year-old woman presented with severe headache. Brain CT showed subarachnoid hemorrhage and angiography demonstrated a ruptured giant basilar bifurcation aneurysm with broad neck, which was treated with a Solitaire AB stent and coils using the waffle-cone technique. The second case involved an 81-year-old man, who presented with dizziness caused by brain stem infarction. Angiography also demonstrated a large basilar bifurcation unruptured aneurysm with broad neck. Solitaire AB stent deployment using the waffle-cone technique, followed by coiling resulted in near complete obliteration of aneurysm. The waffle-cone technique with a Solitaire AB stent can be a useful alternative to conventional stent application when it is difficult to catheterize bilateral posterior cerebral arteries in patients with a wide-necked basilar bifurcation aneurysm.

• Journal of Cerebrovascular and Endovascular Neurosurgery
• /
• v.25 no.2
• /
• pp.196-202
• /
• 2023

One of the common complications that can occur during coil embolization of cerebral aneurysms, is migration of coil lump alone. The removal of these migrated coils has been reported on a few occasions. On the other hand, rare complications would include the migration of the coil with subsequent stent dislocation. Currently, there is no standardized method to correct the complications of stent dislocation, and very few instances of this complication have been reported previously. In this report, we introduce a case of coil migration combined with stent dislocation. This occurred during coil embolization of an unruptured aneurysm of the distal, left internal carotid artery for a 52-year old woman. We retrieved both the damaged stent and migrated coil using another retrievable stent successfully with no more further complications. In the present report, we describe in detail how we corrected the complication successfully stent, and we discuss why this rescue maneuver is reasonable option for the complication mentioned above.

• Journal of Korean Neurosurgical Society
• /
• v.61 no.2
• /
• pp.212-218
• /
• 2018

Objective : Surgical clipping of the cerebral aenurysm is considered as a standard therapy with endovascular coil embolization. The surgical clipping is known to be superior to the endovascular coil embolization in terms of recurrent rate. However, a recurrent aneurysm which is initially treated by surgical clipping is difficult to handle. The purpose of this study was to research the management of the recurrent cerebral aneurysm after a surgical clipping and how to overcome them. Methods : From January 1996 to December 2015, medical records and radiologic findings of 14 patients with recurrent aneurysm after surgical clipping were reviewed retrospectively. Detailed case-by-case analysis was performed based on preoperative, postoperative and follow-up radiologic examinations and operative findings. All clinical variables including age, sex, aneurysm size and location, type and number of applied clips, prognosis, and time to recurrence are evaluated. All patients are classified by causes of the recurrence. Possible risk factors that could contribute to those causes and overcoming ways are comprehensively discussed. Results : All recurrent aneurysms after surgical clipping were 14 of 2364 (0.5%). Three cases were males and 11 cases were females. Mean age was 52.3. At first treatment, nine cases were ruptured aneurysms, four cases were unruptured aneurysms, and one case was unknown. Locations of recurrent aneurysm were determined; anterior communicating artery (A-com) (n=7), posterior communicating artery (P-com) (n=3), middle cerebral artery (n=2), anterior cerebral artery (n=1) and basilar artery (n=1). As treatment of the recurrence, 11 cases were treated by surgical clipping and three cases were treated by endovascular coil embolization. Three cases of all 14 cases occurred in a month after the initial treatment. Eleven cases occurred after a longer interval, and three of them occurred after 15 years. By analyzing radiographs and operative findings, several main causes of the recurrent cerebral aneurysm were found. One case was incomplete clipping, five cases were clip slippage, and eight cases were fragility of vessel wall near the clip edge. Conclusion : This study revealed main causes of the recurrent aneurysm and contributing risk factors to be controlled. To manage those risk factors and ultimately prevent the recurrent aneurysm, neurosurgeons have to be careful in the technical aspect during surgery for a complete clipping without a slippage. Even in a perfect surgery, an aneurysm may recur at the clip site due to a hemodynamic change over years. Therefore, all patients must be followed up by imaging for a long period of time.

• Journal of Korean Neurosurgical Society
• /
• v.66 no.6
• /
• pp.690-702
• /
• 2023

Objective : To analyze the outcomes of coil embolization (CE) for unruptured intracranial aneurysm (UIA) according to region and hospital size based on National Health Insurance Service data in South Korea. Methods : The incidence of complications, including intracranial hemorrhage (ICRH) and cerebral infarction (CI), occurring within 3 months and the 1-year mortality rates in UIA patients who underwent CE in 2018 were analyzed. Hospitals were classified as tertiary referral general hospitals (TRGHs), general hospitals (GHs) or semigeneral hospitals (sGHs) according to their size, and the administrative districts of South Korea were divided into 15 regions. Results : In 2018, 8425 (TRGHs, 4438; GHs, 3617; sGHs, 370) CEs were performed for UIAs. Complications occurred in 5.69% of patients seen at TRGHs, 13.48% at GHs, and 20.45% at sGHs. The complication rate in TRGHs was significantly lower than that in GHs (p=0.039) or sGHs (p=0.005), and that in GHs was significantly lower than that in sGHs (p=0.030). The mortality rates in TRGHs, GHs, and sGHs were 0.81%, 2.16%, and 3.92%, respectively, with no significant difference. Despite no significant difference in the mortality rates, the complication rate significantly increased as the number of CE procedures per hospital decreased (p=0.001; rho=-0.635). Among the hospitals where more than 30 CEs were performed for UIAs, the incidence of CIs (p=0.096, rho=-0.205) and the mortality rates (3 months, p=0.048, rho=-0.243; 1 year, p=0.009, rho=-0.315) significantly decreased as the number of CEs that were performed increased and no significant difference in the incidence of post-CE ICRH was observed. Conclusion : The complication rate in patients who underwent CE for UIA increased as the hospital size and physicians' experience in conducting CEs decreased. We recommend nationwide quality control policies CEs for UIAs.

• Journal of Korean Neurosurgical Society
• /
• v.43 no.3
• /
• pp.131-134
• /
• 2008

Objective: The surgical approach for anterior choroidal artery (AChA) aneurysm is typically similar to those used for other supraclinoid internal carotid artery (ICA) lesions. However, the surgical clipping of this aneurysm is complicated and as a result. can result in postoperative ischemic complications. The purpose of this study was to clarify the risk of clip-induced ischemic complication in AChA aneurysm and to get the benefits for helping decision making. Methods: We retrospectively investigated 53 cases (4.0%) of AchA aneurysm treated surgically. We divided the AChA aneurysm to 3 subtype according to the origin of aneurysmal neck; A type originating from the AChA itself. J type from junction of AChA and ICA and I type from the ICA itself. We evaluated brain CT about 1 week post-operative day to confirm the low density in AChA territory. Results: Ruptured aneurysm was 26 cases and unruptured aneurysm 27 cases. The aneurysmal subtype of A, J, and I was 13, 17, and 23 cases. Of the 53 cases who performed surgical neck clipping, twelve (22.6%) had postoperative AChA distribution infarcts. Increased infarct after neck clipping had statistic significance in non-I subtype (r=0.005) Conclusion: AChA aneurysm surgery carries a significant risk of postoperative stroke. Don't always stick to clipping only, especially in non-I type of incidental small aneurysm, which has high risk of post-clip ischemic complications.